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STATE ID NUMBER <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> ( O1 NEW PERMIT `t ) 05 RENEWED PERMIT ( ) 07 TAMC CLOSED ( ) 09 DELETE FROM FILE (NO FEE) <br /> ( 1 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I 0 O N E R --J- --- _ <br /> NAME(COPPORATION.IND IDUAL OR PVBAjC AGENCY) PUBLIC AGENCY ONLY <br /> 01 FED ( ) 02 STATE t ) 03 LOCAL <br /> FITY <br /> STA ZIP <_ <br /> ST ADDRESS --- ® -- J <br /> ® t <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> I <br /> STRE ADD S - NEARS CROSS STR ET - <br /> COUNT ZIP <br /> CITY Oct. L I . <br /> ro' --- �. <br /> MAILI ADDRESS CITY j ST YIP <br /> PHONE W/AREA COD'E FTYPE OF BUSINESS <br /> D 01 GASOLINE STATION (X 02 OTHER 8 L <br /> .20 <br /> NUMBER OP CONTAINERS <br /> RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> F <br /> : NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. ( l61 TANK t 104 OTHER: CONTAINER NUMBER <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG C. YEAR INSTALLED ( UNKNOWN <br /> D. CONTAINER CAPACITY: GALLONS ( D UNKN�� DOESHE CONTA%NER STORE: ( ) 01 WASTE (.�1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? 0T 01 YES ( l 02 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> ( ) 01 UNLEADED ( ) 02 REGULAR ( D 03 PREMIUM t 04 DIESEL t ) 05 WASTE OIL ( ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM NOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) t 2 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( l 01 DOUBLE WALLED (Ar 02 SINGLE WALLED ( ) 03 LINED - <br /> D. ( ) 12 U( ) 0 O1 CARBON STEEL ( H 02 STAINLESS STEEL t D 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> 6 ALUMINUM ( ) 07 STEEL CLAD ( 108 BRONZE t ) 09 COMPOSITE l D 10 NON-METALLIC <br /> NKNOWN t ) 13 OTHER: <br /> -- PAGE 1 <br /> . HSC04-070185 <br />